- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,090.30 / $8,511.38
| Facility | | $933.25 | $3,090.30 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $8,128.31 / $15,848.93
| Facility | | $3,019.95 | $8,128.31 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,148.15 / $2,951.21
| Professional | | $691.83 | $1,148.15 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,884.03 / $7,413.10
| Facility | | $575.44 | $2,884.03 | $7,413.10 |